2009 Top 40 Assisted Living Chainshttps://www.providermagazine.com/Issues/2009/Pages/2009-Top-40-Assisted-Living-Chains.aspx2009 Top 40 Assisted Living Chains<p>The credit crisis has made its mark on the seniors housing industry over the past 12 months, with lower transaction volumes and higher capitalization rates, according to the National Investment Center for the Seniors Housing & Care Industry. </p> <p>These factors contributed to lower values for assisted living units in 2008, according to Steve Monroe, editor of the <em>Senior Care Acquisition Report</em>.<br></p> <p></p> <div>“The tone of the market has certainly changed, and much of the capital that fueled the bull market from 2005 through 2007 has disappeared, at least for now,” Monroe said. “But it will return.”</div> <h2 class="ms-rteElement-H2">Sunrise Retains Top Spot</h2> <div>This year’s ranking of the Top 40 Assisted Living Chains reveals that Sunrise Senior Living earned the </div> <div>No. 1 spot for the sixth consecutive year.</div> <div><br>The company, which is currently working on meeting its debt obligations, recently replaced its chief financial officer, and staff positions from offices in the United States and Germany were eliminated.</div> <div>Yet, by the end of 2008, Sunrise had expanded its assisted living division and reported operating 391 facilities in 40 states, with a total assisted living resident occupancy capacity of 49,481—an increase of 13,341 above the 2007 level.</div> <div><br>Seattle-based Emeritus earned the No. 2 position, the same position as last year. The company also reported an expanded capacity. At the end of 2008, Emeritus operated in 37 states, with 306 facilities and an occupancy capacity of 32,000. In 2007, Emeritus reported operating 287 facilities and an occupancy capacity of 29,522 assisted living residents.</div> <div><br>No. 3 is Brookdale Senior Living, located in Brentwood, Tenn., operating with 409 facilities and a capacity of 21,021 in 34 states at the end of 2008. In the No. 4 position, Atria Senior Living operates in 27 states with a total occupant capacity of 14,400. Expanding its operations and jumping to the No. 5 position is Five Star Quality Care, which has 144 facilities, an occupant capacity of 9,682, and operating in 24 states. In last year’s Top 40, Five Star was in the No. 7 position with 112 facilities and an occupant capacity of 6,330.</div> <div>In the No. 6 spot is Assisted Living Concepts, operating 216 facilities in 20 states and total occupant capacity of 9,154. </div> <div><br>Merrill Gardens, headquartered in Seattle, is in the No. 7 spot, with 54 facilities operating in nine states and an occupant capacity of 7,070. Last year, Merrill Gardens reported operating 53 facilities and an occupant capacity of 6,770. </div> <div><br>No. 8 is HCR ManorCare, with a total of 65 facilities with assisted living and an occupant capacity of 5,080. In the No. 9 spot is One Eighty-Leisure Care, which operates in seven states, with 29 facilities and an occupant capacity of 4,667. </div> <div><br>In the No. 10 position is Benchmark Assisted Living, located in Wellesley, Mass., operating in six states with 44 facilities and a total occupant capacity of 3,992. </div> <h2 class="ms-rteElement-H2">Services Expand</h2> <div>Assisted living providers also expanded their services last year, in nearly all categories. Twenty-nine companies include therapy services in their repertoire, compared to 21 companies last year. Hospice care has also become more popular, with 24 companies—eight more than last year—offering the service to residents.<br><br></div> <div>More modest growth was seen for other services, such as pharmacy and outpatient therapy, which are now offered by 14 and 20 companies, respectively. </div> <div><br>Thirty-two of the Top 40 companies offer independent living units, as opposed to 29 companies last year.<br><br><img width="26" height="27" src="/reports/PublishingImages/pdf_download2.png" class="ms-rtePosition-4" alt="" style="margin:5px;" />Download the <a href="/reports/Documents/2009/Top%2040%200609.pdf" target="_blank">Top 40 list</a> here.<br></div> <p><br><br></p>This year’s ranking of the Top 40 Assisted Living Chains reveals that Sunrise Senior Living earned the No. 1 spot for the sixth consecutive year.2009-06-01T04:00:00Z<img alt="" src="/Issues/Special-Features/PublishingImages/Top40.jpg" style="BORDER:0px solid;" />CaregivingSpecial Feature6
2009 Top 50 Nursing Facility Chains https://www.providermagazine.com/Issues/2009/Pages/Top-50-Weathering-The-Storm.aspx2009 Top 50 Nursing Facility Chains <div> </div> <div>Despite a tempestuous year for the real estate industry, most experts agree that the seniors housing sector has thus far weathered the economic storm relatively well. Some encouraging fundamentals from the National Investment Center for the Seniors Housing & Care Industry (NIC) appear to bolster this view: Mean occupancy rates for assisted living, skilled nursing, and continuing care retirement communities, for example, held steady from the third to the fourth quarters in 2008. </div> <div> </div> <div>What’s more, loan performance deterioration during the fourth quarter of 2008 was still well below the 10 to 15 percent levels of nonperforming loans that the industry experienced during the last downturn six to seven years ago, according to Lawrence Horan, NIC’s financial research and analysis director.</div> <div> </div> <div>While most experts agree that the outlook for the next 12 months is sunnier, there is a dark cloud on the horizon: the specter of some $390 million in cuts to Medicare skilled nursing facility funding for next year.</div> <div> </div> <div>On the following pages is <em>Provider’s</em> annual ranking of the top 50 nursing facility companies, by the number of nursing beds, as of Dec. 31, 2008. The data indicate the 50 leading companies’ 2008 revenue, occupancy rates, and extent of regionalism. </div> <h2 class="ms-rteElement-H2">Reflections Of The Economy</h2> <div>This year’s ranking perhaps reflects the economic turmoil of the past 12 months, with a total bed count reduction of 14,827 compared to last year.</div> <div><br>Only three of the top 10 companies reported gains this year—Genesis Healthcare Corp., Skilled Healthcare, and National HealthCare Corp. expanded by a total of 5,561 beds—while the remaining seven had modest dips in bed counts.   </div> <div><br>Otherwise, HCR ManorCare retained its status this year as the leader of the pack, while all of the top four companies held steady. Golden Living, Life Care Centers of America, and Kindred Healthcare remained at Nos. 2, 3, and 4, respectively. </div> <div><br>Genesis HealthCare grabbed the No. 5 spot from Sun Healthcare Group, which inched down to No. 6.</div> <div>Extendicare Health Services slid one space up from last year, to No. 7, filling the spot left open by SavaSenior-Care, who did not participate in the rankings this year. </div> <div><br>The remaining three top 10 companies were jostled slightly, with Evangelical Lutheran Good Samaritan Society moving up from No. 9 to No. 8 and Skilled Healthcare Group holding at No. 10.</div> <div><br>National HealthCare slid past Skilled Healthcare to take up the No. 9 slot this year with a bed count gain of over 600.</div> <div><br>Two companies, Trilogy Health Services and Americare, made notable jumps in the rankings this year through acquisitions of more than 1,600 beds combined. Trilogy leaped 10 slots, from No. 28 to 18, with 1,280 new beds, while Americare rose seven slots with an additional 463 beds, from No. 50 to No. 43 this year.</div> <div><br>There is one newcomer to this year’s ranking: Stonegate Senior Care of Lewisville, Texas, who joins the list at No. 26 with 3,590 beds. </div> <h2 class="ms-rteElement-H2">Companies Up Services</h2> <div>Renovation activity remains steady among the top 50, with nearly all respondents indicating they would either begin or complete renovations of some facilities this year. More than 36 companies are adding rehabilitation suites or units, and 16 are planning to add new services such as Alzheimer’s care, secured units, or respite rooms.<br></div> <div><br>Two companies have added home care to their menu of business units, while 24 companies now offer hospice.</div> <div><br>Up from last year are the number of companies offering ventilator services: 23 providers this year, compared to 19 last year.</div> <div><br>The information in these rankings was collected through e-mail, Web sites, phone interviews, and faxed surveys. Only partial data were obtained for a number of private companies, which are not required to make public certain information. <br><br><img width="35" height="36" class="ms-rtePosition-1" src="/reports/PublishingImages/pdf_download2.png" alt="" style="margin:5px;" /><br>Click here to download the <a title="Download the 2009 Top 50 List" target="_blank" href="/reports/Documents/2009/Top%2050%200609.pdf">2009 Top 50 </a>list.</div>Despite a tempestuous year for the real estate industry, most experts agree that the seniors housing sector has thus far weathered the economic storm relatively well.2009-06-01T04:00:00Z<img alt="" src="/Issues/Special-Features/PublishingImages/Top50.jpg" style="BORDER:0px solid;" />CaregivingSpecial Feature6




Pursuit Of Quality: Ongoing Questhttps://www.providermagazine.com/Issues/2009/Pages/Pursuit-Of-Quality-Ongoing-Quest.aspxPursuit Of Quality: Ongoing Quest<div>​When the 2009 American Health Care Association/National Center for Assisted Living Quality Award recipients were announced this summer, many facilities celebrated a milestone in their efforts to maximize quality of care for their residents and quality of life for residents and staff. While all were pleased to receive this award—whether they were honored for reaching Step I, Step II, or Step III—few were surprised.</div><div><br></div> <div>As Shelly Fink, executive recruiter at Altercare of Ohio, notes, “Our organization has many wonderful characteristics that have led us to this success. We are committed to learning and skills development. We have a strong rewards program, an emphasis on recruiting and retention, corporate leadership with a strong vision and mission, and demonstrated support for innovation. We worked hard for this achievement, and we’re very proud, but we weren’t surprised. Quality care is who we are every day.”</div> <h3 class="ms-rteElement-H3">Step III: Making It Look Easy</h3> <div>Facilities reaching Step III made it look easy, partly because quality and excellence already were so engrained in their cultures. As Lee Larson, administrator at St. Gertrude’s Health & Rehabilitation Center in Shakopee, Minn., says, “We’re part of an organization that’s never satisfied with standing still. Striving for quality—using pillars of strategic planning that include financials, care, services, and people—is part of who we are and what we do every day. We need to continually make this a better place for residents to receive care and for staff to work. Going through the step processes embedded this even more.” </div> <div> </div> <div>Jane Goebels, nurse administrator at St. Gertrude’s, says, “Ever since we’ve been in existence, it has been a requirement for us to have a quality assurance program, then quality measurement, then quality improvement. We have had strategic planning for at least 10 years.” She adds, “We have had expectations by our leadership group that we would be an education organization. And our leadership has been critical to our success by putting processes in place and enabling them to be implemented easily and affordably.” </div> <div> </div> <div>This commitment to quality and change just seemed to grow as Larson and his team moved through the steps. As Goebels says, “Step II made us look at our strategic planning efforts—including a SWOT [Strengths, Weaknesses, Opportunities, and Threats] analysis—and made us realize that we needed quality improvement as part of our strategic planning. Now, with Step III, this has become the driving force of our strategic planning. It involves all areas and all staff at the facility,” she says.</div> <div> </div> <div>Anna Bojarczuk-Foy, administrator at ElderWood Health Care at Wedgewood in Amherst, N.Y., says “Our owner has always had a vision of challenging staff toward a pursuit of excellence. As a facility, we decided to undertake this journey—although we didn’t look all the way to Step III when we started.” </div> <h3 class="ms-rteElement-H3">Seeing The Big Picture</h3> <div>Step III award winners credit the application process with helping them to see the big picture of how far they have come. For example, at one time in the past, St. Gertrude’s noticed that its family satisfaction scores had declined.</div> <div> </div> <div>“We instituted a partnership with a family initiative that took place at family council meetings. We met with family members individually and talked about our desire to partner with them using a quality management process to identify areas where we weren’t meeting their needs,” says Goebels. The facility implemented consistent assignments/staffing, addressed dining room issues, started a family newsletter, redesigned bathrooms to be less institutional and more spa-like, and extended more flexibility in dining, bathing, and rising and retiring to bed times. </div> <div> </div> <div>“As a result, we really have forged a positive relationship with families, and the improvements we instituted led to improvements in scores—in the top quartile nationally—and better communication between families and staff,” she says. “When we won this award, families were excited for us but not surprised. And we realized how far we’d come in forging this positive relationship.”</div> <div> </div> <div>“Going through Step III made us realize the importance of communication. Sometimes we forget that,” says Mark Cairns, administrator and chief executive officer (CEO), Madonna Living Community in Rochester, Minn.</div> <div>“When we wrote the application, it came back to us the importance of communicating back to staff the role they play in ways we haven’t done before. We actually brought together focus groups to find out what staff expect from communication. We found that staff wanted more postings of minutes and sharing of what goes on in management teams,” he says, adding, “We are now trying to provide as much information in as many different ways as possible.”</div> <div> </div> <div>Cairns notes that they also discovered the alphabet soup of abbreviations and acronyms they used—such as the MDS (minimum data set) and MARs (medication administration records)—were confusing for some. “We developed a glossary of terms for board members and others to help them understand what these things mean and to make sure everyone has the same understanding of different terms,” he says. </div> <h3 class="ms-rteElement-H3">The Challenges Of Climbing To Step III</h3> <div>Getting to Step III wasn’t easy, the award winners admit. “You really have to have systems in place to get here. You need processes to measure, analyze, and decide what you will do with this information,” says Goebels. “Along with that, you have to roll that information into strategic planning and leadership. Then you have to walk people through the processes and make your organization a learning body,” she says.</div> <div> <br>“We really looked at how our processes and our QI system worked, and we developed our game plan,” Bojarczuk-Foy says. “By doing Step III, we actually communicated this plan at every level. It became part of staff orientation, the lingo used at every meeting, and every system we employ. It is a verbal reminder that we all have to be on the same page with our goals, actions, approaches, and how we will monitor and measure outcomes and implement change.” </div> <div> </div> <div>A key part of this game plan is the Wedgewood System Wheel, which substitutes for the facility’s organizational chart, “the spokes of which are the concepts that we are constantly reaching for—education, clinical outcomes, communication, technology, and so on. This is not just something on paper; it’s what we do and who we are,” Bojarczuk-Foy says.</div> <div> </div> <div>Wedgewood uses an acronym for it game plan that everyone can understand—“g” is for goals, “a” is for approach, “m” is for monitoring, and “e” is for evaluation. “We use this for everything from how we wash the dishes to what we do to make sure we don’t develop any in-house pressure ulcers. We talk about everything we have to do from a communications, clinical, and education perspective. As a result of all of this, we have formed a nice, close-knit team,” says Bojarczuk-Foy.</div> <h3 class="ms-rteElement-H3">Lessons Learned</h3> <div>Even though the Step III application process was rigorous and designed to document what facilities have accomplished and learned already, Larson says they learned much as they pursued the award. “It forces you to quantify and sharpen your quality measures and track outcomes over time,” he says. </div> <div> </div> <div>“Having a strong emphasis on statistical significance and seeing it all laid out over a period of years gives you a chance to see the big picture and how your facility has really performed over time.” </div> <div> </div> <div>Criteria, patterned after the Malcolm Baldrige national quality awards, “set up a benchmarking system that relies on outcome measures at various points,” Bojarczuk-Foy says. “We learned that you have to systematically measure your progress at various points and levels to make sure you are going in the directions you want and that you can react quickly when there is a problem or need for change. That was huge for us.”</div> <div> </div> <div>Not surprisingly, Step III award winners have high standards for themselves. They always are looking for ways to do better and be better. However, winning the award gave them an opportunity to step back and appreciate what they have accomplished.</div> <div> </div> <div>“We were amazed when we looked at what we had gone through,” says Goebels. “When you pursue quality on a daily basis, you tend to focus on what you still need to accomplish. When we saw our achievements in writing, they were pretty big.”</div> <div> </div> <div>“When you step back, you’re able to see the progress of going from Step I to Step III. It’s like going from grade school to high school to college,” says Bojarczuk-Foy. “I actually believe there should be a fourth step—not an award, just a step that facilities can strive for that promotes ongoing growth.” Bojarczuk-Foy and her team also learned the importance of ongoing communication and ensuring that everyone is on the same page and has the same understanding of goals.</div> <div> </div> <div>The award’s impact on morale can’t be underestimated, Larson says. “It helps staff feel more strongly that this is a place that they feel proud of and where they want to work.” The good feelings also have extended to the community—including family members and other stakeholders. As Larson says, “We’ve gotten a lot of positive feedback. It raises the perception in the community of what senior care is all about and expectations about what it can do.”</div> <div> </div> <div>“One of my goals for this was to be able to show what staff is really doing and what they are accomplishing through their dedication and loyalty,” says Cairns. “This was a chance for us to tell our staff what they are doing right and talk about how wonderful our staff is.” </div> <div> </div> <div>Cairns was eager to share the good news about the award with everyone. “We announced it to staff as soon as we got the news that we won. We also announced it to nearly 600 people at our family picnic. We ran a full-page ad in the local newspaper with everyone’s name in a list, and we purchased special t-shirts for everyone,” says Cairns. “When people ask, they’ll be able to say that it’s the highest award you can receive.”</div> <h3 class="ms-rteElement-H3">Step II: Success Stories Abound</h3> <div>All Step II recipients said they look forward to pursuing Step III, and they encourage facilities that haven’t started this journey to set their eyes on Step I.<br><br>Applying for the Step II award gave facilities an opportunity to reflect on their quality successes. Their stories suggest the power of a commitment to quality and the consistent use of processes to solve problems.</div> <h3 class="ms-rteElement-H3">Hartford Health Care</h3> <div>Les Hogan, administrator, Hartford Health Care in Hartford, Ala., says, “We discovered that there wasn’t a diagnosis to support the use of antipsychotics in all of our patients. We identified ways we could decrease the use of these meds. We reviewed each chart, making sure there was a diagnosis and a need for the antipsychotic. </div> <div> </div> <div>“We not only improved quality of care but also improved financial quality by saving money spent on those drugs; we also reduced the time nurses had to spend on medication administration.”</div> <div> </div> <div>Once Hogan’s team identified the problem, they were able to move through the process easily. They focused on one hall per month and completed the process in a six-month period. The result was a reduction in antipsychotic use from 33 percent to 6 percent. </div> <div> </div> <div>Teamwork and communication made this process successful, according to Hogan. </div> <div> </div> <div>“The medical director was very supportive and worked with nurses to determine when meds could be discontinued or doses reduced,” he says. “If patients were cognitive enough, we talked to them about it; if not, we spoke with the family. As we slowly titrated the meds down, we constantly monitored patients—including their behaviors—to make sure there were no adverse reactions.” </div> <h3 class="ms-rteElement-H3">Maryhill Manor</h3> <div>At her facility, Maryhill Manor in Niagara, Wis., Jana Clement, administrator, president, and CEO, and her team focused on making meals more homelike for residents.</div> <div> </div> <div>“We wanted to work toward something that would let our residents feel empowered. We started with enhanced meals and kept a list of goals. The change didn’t happen all at once. Several action teams each took a section of the process and worked at developing something to make it feasible. </div> <div> </div> <div>“At the same time, we developed interest sheets on which residents could write something they wanted. From there, we developed the dining program,” she says.</div> <div> </div> <div> The facility started a five-meal plan, but it was discontinued because the residents didn’t want it. They also didn’t want buffet style dining; they wanted to be served restaurant style. “We moved from neighborhood to neighborhood with natural risings. Residents now can choose from a menu, and we can create special foods as they desire. The residents love it, and it’s been a wonderful growth experience for staff,” says Clement.</div> <h3 class="ms-rteElement-H3">Golden LivingCenter</h3> <div>Amy Wall, executive director, Golden LivingCenter, Decatur, Ga., and her team started their enhanced dining program by “getting rid of all the plastic because you don’t eat off plastic at home. Instead, we use china and silverware, and we have tablecloths and centerpieces. We start the meal with a beverage cart, and we initiated a dessert cart. We also have a soup course that enables us to get a few more calories in the residents.” </div> <div> </div> <div>Residents are brought in early enough to socialize before meals if they so desire. They can choose between the featured menu item, an alternative, or other options such as a salad, burger, or grilled cheese sandwich.</div> <div>In dining areas, dietary aides run the show, and certified nurse assistants help. </div> <div> </div> <div>“Everyone loves it,” says Wall. “It helps maintain weights, it has decreased waste in the kitchen, and residents like that they feel as if they are dining in a restaurant.”</div> <h3 class="ms-rteElement-H3">Golden LivingCenter—St. James</h3> <div>In preparing her facility’s Step II application, Renee Riding, executive director, Golden LivingCenter—St. James in St. James, Mo., at first had trouble answering a question about how her facility promoted diversity. But as she pondered this, she realized that her team actually had made a huge step forward in this area. “It hit me that for us diversity means looking at the available staff pool. We had looked at recruitment and retention and why we lose people,” she says.</div> <div> </div> <div>Riding and her team discovered that many in their potential workforce were single moms who had trouble feeding their families and getting to work. “It occurred to us that these people often don’t have the resources to pull themselves out of the hole. So we created the ‘helping hand pantry,’ stocked with staple food items, gas cards, and other things our workers need. When someone needs help, they come to the pantry. It’s based on the honor system, and people are supposed to pay back what they used when they get their paycheck,” says Riding.</div> <div> </div> <div>“We’ve been doing this for about two years with very positive results. We have much less turnover, and people can focus more on their work and worry less about feeding their families or having gas to get to work,” she says.</div> <h3 class="ms-rteElement-H3">Oak Hill Nursing and Rehabilitation Center</h3> <div>Improving quality in the risk assessment area was an important goal for Scott Sanborn, executive director, and his team at Oak Hill Nursing and Rehabilitation Center (Kindred Healthcare) in Pawtucket, R.I.</div> <div> </div> <div>“We established a multi-pronged process that works for us,” he says. The facility has daily clinical meetings that involve licensed nurses, plus activities, rehab, and other staff. Then they have a once-weekly at-risk meeting where they discuss all patients who have risk factors in any area.</div> <div> </div> <div>“We develop action plans right there on the spot—whether that means a new order from the attending physician, a change in diet, or other intervention. Everything is documented at the meeting, and everyone is there to hear the plan and discuss their role in it. It puts everyone on the same page and enables us to be proactive; and everything happens in real time,” Sanborn says.</div> <div> </div> <div>As a result, the facility has seen steady improvements in quality indicator numbers for pain control, wound care, and other areas. “We’ve set targets, met them, set new ones, and met those,” he says.</div> <h3 class="ms-rteElement-H3">Spa Creek Center</h3> <div>A few years ago, Administrator Margaret McGovern and her team at Spa Creek Center (Genesis HealthCare) in Annapolis, Md., realized that their admissions were down, so they initiated a customer service focus. “We made sure our department heads and nursing managers were informed and educated. We hired a company that conducts staff satisfaction surveys, and we conducted an annual resident satisfaction survey. We trend and monitor this data regularly,” she says.</div> <div> </div> <div>In addition to initiatives such as enhanced dining programs, spa-like bathrooms, and a beauty salon for residents, McGovern’s team also has done much to improve staff satisfaction. “We have an employee relations committee that organizes employee activities every month. We celebrate birthdays and have special meals for staff. We have an employee recognition dinner and awards ceremony. We recognize retention,” she says.</div> <div> </div> <div>The result? According to McGovern, “Our last survey showed that 100 percent of patients would refer a friend or family member to the facility; the number for staff was 92 percent,” she says. </div> <h3 class="ms-rteElement-H3">Lessons Learned</h3> <div>As with the Step III award recipients, Step II winners learned much from going through the application process. As Hogan notes, “It taught me just how intertwined every aspect of the facility is with every other one. For example, what the bookkeeper does affects nurses. If the patient isn’t admitted correctly and the payer source isn’t identified, it affects nurses ordering the meds. This helped me understand the need for consistent education and training to keep everyone on the same page.” </div> <div> </div> <div>Wall says, “When you piece all of the information and data together and look at results over a year, it’s interesting to see how people in the facility have maintained benchmarks set by the corporation. When you start showing things like your turnover are under benchmark year after year, it’s easier to show how your quality measures have improved.” </div> <div> </div> <div>Sometimes facilities learned about areas where quality could be improved. According to Anthony Hanson, administrator, Prince of Peace Care Center (Benedictine Health System) in Ellendale, N.D., “We came up with some glaring information that told us things we thought we were doing right could be done better. We learned that if one process doesn’t work, you try another to get the results you want.”</div> <div> </div> <div>Riding says, “We realized that we don’t always tell our story as well as we could sometimes. It made us focus more on how we communicate with residents and families, as well as staff.”</div> <h3 class="ms-rteElement-H3">Culture Change, Step II Go Hand In Hand</h3> <div>Most Step II recipients say they understood the value of quality improvement and culture change before they even thought about the award. Hogan says, “Our team knows their ideas will be respected and that they can come to management with their ideas. We’ve long believed in bringing everyone together to accomplish quality care and that everyone on the team is important and has a key role."</div> <div> <br>“You need to have undergone culture change before you can move through the quality steps. If you don’t have a culture that values staff, you will encounter resistance when you try to evaluate your process,” says Roy David, administrator, Van Dyk Manor of Ridgewood in Ridgewood, N.J. “You couldn’t go through this process without knowing you have the full backing of your people and without having strong processes in place,” he says. At the same time, “moving through the steps validates the change itself and helps you solidify your culture change activities. The award is the icing on the cake,” he says.</div> <div> </div> <div>Celebrations for reaching Step II were common and festive. Clement says, “We’re a small facility, and we celebrate our lives together. We made announcements on the loudspeaker, put an article in our newsletter, celebrated with a party, and passed out key chains. </div><div><br></div> <div>“We took photos when we made Step I, and the pride on everyone’s faces is amazing,” she says. “Winning these awards reminds us all of how much we impact residents and each other.”</div> <div> </div> <div>Wall says, “I think my staff heard me yell when I got the news that we’d won [Step II]. Staff were extremely proud, and while residents were happy, they weren’t surprised. They already were living the improvements.”</div> <div> </div> <div>Like many quality award recipients, Riding uses the reward in staff recruiting efforts. She says, “We put it in the ads. We let people know that this is an award-winning facility with high standards. We tell applicants that they may make more money at another facility, but working here will give them an opportunity to participate in a facility that has quality systems in place. They will learn to do things the right way and with integrity.” </div> <h3 class="ms-rteElement-H3">Looking Up And Ahead</h3> <div>Whether a facility has reached Step II or III, its progress has made leadership and staff look up and gaze to the future. “Sometimes, we have our heads down, so focused on what we need to do that we forget to look up and see where we are and how far we’ve come,” says Cairns. “This award has made us lift our heads high and take pride in ourselves and our industry.”</div> <div> </div> <div>Hanson adds, “We’ve dedicated ourselves to this journey and are looking ahead to Step III. It will be one gigantic standard setter, and we welcome the opportunity to go there.” </div> <div> </div> <div><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div>When the 2009 American Health Care Association/National Center for Assisted Living Quality Award recipients were announced this summer, many facilities celebrated a milestone in their efforts to maximize quality of care for their residents and quality of life for residents and staff. 2009-10-01T04:00:00Z<img alt="" src="/PublishingImages/default-article-image.png" style="BORDER:0px solid;" />Quality;Quality AwardsSpecial Feature10





Providers Collaborate On Quality Initiativeshttps://www.providermagazine.com/Issues/2009/Pages/Providers-Collaborate-On-Quality-Initiatives.aspxProviders Collaborate On Quality Initiatives<p>​What is quality? The answer changes depending on who one asks.</p> <p>Quality to Eileen Kramer, for example, spokesperson for Peabody Home in Franklin, N.H., which recently won a Quality of Life Award from the local Department of Health and Human Services, says that quality is all about culture change. It is about “transforming a nursing facility into a home, a patient into a person, and a schedule into a choice,” Kramer says.</p> <p>“Our most important measure of quality is whether we are satisfying the needs and desires of our residents and their families,” says Scott Pilgrim, who owns or manages four long term care facilities in Oklahoma. “Our success depends upon their satisfaction.”</p> <p>In long term care, the profession and government alike are pressing for more and faster quality improvement with an array of initiatives and tools. At the same time, the recession and cuts to Medicaid in many states, among other factors, have made just remaining operational difficult, much less finding the physical, personnel, and financial resources to expend on quality improvement efforts.</p> <p>Still, perhaps because of the initiatives, virtually all nursing facilities are actively working to improve their quality, according to a new report, the “2009 Annual Quality Report,” published this September by the American Health Care Association (AHCA) and the Alliance for Quality Nursing Home Care, both of Washington, D.C. With the well-being of the resident at heart, as always, long term care facilities are finding a way to make it happen.</p> <p>The report is the sector’s first to comprehensively examine quality trends in nursing facilities across the United States, and it found that quality is improving, particularly for facilities that are taking advantage of the Advancing Excellence quality initiative (see Table 2).</p> <div>A related study, “Changes in the Quality of Nursing Homes in the U.S.: A Review and Data Update,” published in August and written by Vincent Mor et al. found that “quality” isn’t a simple thing to measure. Mor is a professor and chair of the Department of Community Health at the Brown University School of Medicine.</div> <h3 class="ms-rteElement-H3">Quality Has Improved</h3> <p>Quality is multi-dimensional in long term care residences, said Mor, going far beyond quality of care to being a literal home that has very satisfied residents and families, committed staff, financial stability, and operational efficiency, along with a host of other components. </p> <div> </div> <div>Quality is also a moving target; a facility never “gets there” and “just maintains.” Quality, as nearly all nursing facilities have demonstrated, involves a continuing process of improved data collection, analysis, process implementation or alteration, monitoring, and feedback.</div> <div> </div> <div>Both studies found that as nursing and rehabilitation facilities are in the midst of numerous changes, from technological to cultural to case-mix makeup, quality does appear to be improving. </div> <div> </div> <div>Relying primarily on publicly available government data and findings from some of the country’s leading researchers in long term care, the “2009 Annual Quality Report” surveyed organizations representing 5,713 nursing and rehabilitation facilities, along with 631 independent facilities. </div> <div> </div> <div>This survey, conducted between April and May of this year by Avalere Health, Washington, D.C., was designed to determine the extent to which Quality First is being used by facilities to improve quality and identify areas needing improvement. The survey showed that the majority of facilities do frame their quality improvement efforts using many of the elements of the Quality First pledge.</div> <div> </div> <div>The report shows that virtually all—99 percent—of facilities have a continuous quality improvement program, and all—100 percent—have taken at least one step toward improvement in the Centers for Medicare & Medicaid Services’ (CMS’) 10 quality measures used in the Five-Star Quality Rating Program.</div> <div> </div> <div>In addition, quality has particularly improved in a number of clinical areas, the quality report says, citing data from the Office of Inspector General.</div> <h3 class="ms-rteElement-H3">Gains Are Huge </h3> <p>Between 1999 and 2007, the prevalence of dehydration dropped a whopping 81.3 percent, to 0.3 percent. The percentage of restrained residents plummeted by 50.5 percent, to 5.2 percent. </p> <div>The improvement in quality measures between 1999 and 2007 goes on and on (see Table 1, page 22). The number of residents who spend most of their time in bed or in a chair dropped 40 percent, while the prevalence of little or no activity dropped 75.7 percent, and the percentage of residents losing weight dropped 19.5 percent, to 9.9 percent. The percentage of residents experiencing pain fell 36.5 percent, to 8.7 percent. </div> <div> </div> <div>According to the Mor report, national survey data show that the percentage of nursing and rehabilitation facilities cited for substandard care decreased by 11 percent between 2000 and 2009. This was at the same time that the number of deficiencies overall increased by a bit more than one deficiency per nursing and rehabilitation facility.</div> <div> </div> <div>“Most of the CMS-reported outcome measures, particularly for the long-stay population, have improved over time from ADL [activities of daily living] decline to facility-acquired pressure ulcers,” said Mor. </div> <div> </div> <div>He did note, however, that incontinence has worsened and that psychotropic drug use has increased, but the authors attributed this to greater use of antidepressants rather than to the use of antipsychotics, which seems to have leveled off.</div> <div> </div> <div>And the quality report’s authors found evidence that, despite not being measured by CMS, satisfaction survey results are important measures of quality.</div> <h3 class="ms-rteElement-H3">Satisfaction Surveys Key Measures</h3> <div>“We now have empirical evidence that ongoing national collaborative partnerships such as the Quality First initiative, CMS’ Nursing Home Quality Initiative, and the Advancing Excellence in America’s Nursing Homes campaign may be helping to improve levels of consumer and workforce satisfaction nationwide,” wrote the quality report’s authors.</div> <div> </div> <div>In fact, satisfaction has improved in nursing and rehabilitation facilities across the country, according to the “2008 National Survey of Consumer and Workforce Satisfaction in Nursing Homes” released by My InnerView in May of this year.</div> <div> </div> <div>My InnerView provides and tabulates results of a national consumer and workforce satisfaction survey tool used by more than 5,000 nursing and rehabilitation facilities that assess performance and use the data to improve organizational excellence. My InnerView, based in Wasau, Wis., also establishes performance benchmarks. The database developed from the survey results is by far the largest ever assembled in the long term care sector, drawing on the responses from 425,000 residents, families, and workers.</div> <div> </div> <div>Eighty-five percent of consumers (patients and families) rated their overall satisfaction as either excellent or good, an increase of 3 percent from 2007 to 2008. Those rating their satisfaction as excellent increased from 31 percent in 2007 to 35 percent in 2008. Eighty-one percent of consumers would recommend their facility to others. The most important factors for whether a resident or family member would recommend a facility all had to do with staff: whether they show concern, their competence, the quality of their service, and their attention to residents’ choices and preferences.</div> <div> </div> <div>“Staffing levels are often thought of as the sine qua non of nursing home quality since without adequate staff it is not possible to care for the frail population,” wrote Mor, citing several studies. </div> <div> </div> <div>Mor found that “when all facilities are averaged, we see growth in the number of aides per resident day, the number of licensed practical nurses per day, and stability in the number of RNs [registered nurses] per resident day.”</div> <div> </div> <div>Consumers (residents, patients, and family members) and workers did identify areas needing more improvement: greater choice, better communication from management, and more relief from significant job stress. A recent My InnerView paper, “Leadership Competencies and Employee Satisfaction in Nursing Homes,” found that leadership competencies were strongly correlated with worker satisfaction. The paper recommended that providers develop leadership competencies to further quality improvement efforts.</div> <h3 class="ms-rteElement-H3">Staff Satisfaction Important</h3> <div>“Clearly, an effective strategy for quality improvement has to include a focus on the workforce that provides care for residents and their family members,” wrote the quality report’s authors. </div> <div> </div> <div>Many providers are using the satisfaction surveys to identify areas needing improvement and to make changes to resolve those issues, the quality report says. For example, 51 percent of providers surveyed “have made changes to dining selections and/or implemented an open dining program [that] allows residents to eat according to their own schedules and needs,” the report’s authors wrote.</div> <div> </div> <div>Others changed laundry providers, created more spiritual opportunities for residents, changed the types and variety of resident activities, changed staffing levels or assignments, and restructured case management and discharge planning. A full 77 percent increased training on issues raised by the satisfaction surveys. </div> <div> </div> <div>Ninety-six percent reported improved quality as a result of being able to use satisfaction survey data to identify quality problems and monitor improvements.</div> <div> </div> <div>Sixty-six percent of workers said their facility was an excellent or good place to work, and 73 percent said it was an excellent or good place to receive care. Management practices were the most important factors to workers. </div> <div> </div> <div>Mor’s findings indicated that the proportion of facilities with high levels of nurse staffing has increased. However, Mor also saw an increase in the proportion of facilities whose nurse staffing has fallen below minimum levels. </div> <div> </div> <div>Mor noted that most measures of staffing ignore therapists, the fastest-growing segment of facility staffing, especially at facilities with many Medicare patients. </div> <h3 class="ms-rteElement-H3">The Reimbursement Link</h3> <div>Among the quality report’s key findings was a strong correlation between adequate reimbursement rates and quality improvements, along with access to care. The report’s authors urged policy makers to keep reimbursement rates for public programs stable.</div> <div> </div> <div>“Because facilities devote a full 70 percent of operating expenses to wages, benefits, and other labor costs,” Alan Rosenbloom, president of the Alliance, said in a statement. “Medicare funding stability from Washington is essential to the ongoing successful operation of our quality improvement programs.”</div> <div> </div> <div>Mor observed that higher Medicaid reimbursement rates “appear to be associated with great improvements in </div> <div>quality and lower rates of hospitalizations.”</div> <div> </div> <div>In fact, facilities that rank lowest in quality tend to have more Medicaid patients and are much more likely to fail and have chronic quality problems, according to a number of studies. Other studies have shown a correlation between higher state Medicaid reimbursement rates and nursing facility quality. Higher payment rates have been found to be associated with fewer pressure ulcers, more staffing, fewer hospitalizations, fewer physical restraints and feeding tubes, and fewer government-cited deficiencies, Mor said. </div> <div> </div> <div>Further, the report found mounting evidence that rehabilitative and medically complex care is more cost-effective in nursing and rehabilitation facilities than in other sites, such as inpatient rehabilitation facilities.</div> <h3 class="ms-rteElement-H3">Providers Contemplate Techniques</h3> <div>Virtually all nursing facilities are involved in some kind of quality improvement, according to the quality report, especially continuous quality improvement (CQI), which is a management philosophy of injecting quality processes into all operations to improve resident and family satisfaction and patient outcomes. The CQI effort may include monitoring patient conditions, holding training sessions on quality improvement techniques, and making care more effective.</div> <div> </div> <div>Mark Cairns, administrator of Madonna Living Community in Rochester, Minn. (owned by Benedictine Health System [BHS]), and Assistant Administrator Beth Redalen say their quality improvement efforts have really paid off for the residents, as well as in an AHCA/National Center for Assisted Living (NCAL) Step III Quality Award. Tracking that improvement is a satisfying experience. </div> <div> </div> <div>“We’ve made great strides in falls and pain,” says Redalen, “and have tracked those [among other indicators] for the last three years. We’ve substantially met the goals because of new processes that we’ve put in place.”</div> <div>“I feel that whether it was the quality award or any of the initiatives,” says Cairns, “what it does is help you focus in on an area so you can measure it. Then you start tracking it and try to benchmark it against other facilities. Once you get those answers, you develop a process so that you can maintain that quality level.”</div> <div> </div> <div>To improve quality, Redalen says, first measure performance. This allows identifying opportunities for improvement. Once these are identified, come up with—and implement—an action plan for addressing the issue, she says. Continue to measure performance in order to track the progress being made, and generate reports on the progress of various quality improvement efforts. These can be used for comparative data, public reporting, pay for performance, and accreditation, Redalen says.</div> <h3 class="ms-rteElement-H3">Going After The Primary Cause</h3> <div>One way to determine and eradicate the root cause of a problem is called root cause analysis (RCA). The premise is that by eliminating the root cause of a problem, rather than “treating the symptoms,” the likelihood that the problem will recur is minimized, experts say. RCA needs to be conducted systematically, using documented evidence for all conclusions. When investigating the root cause, remember that usually more than one potential root cause exists. To determine the correct causes, document all known causal relationships between the causes and the problem. </div> <div><br></div><div>Once that’s done, providers should figure out a solution that could prevent recurrence, provided the solution meets the facility’s goals and objectives and it doesn’t cause other problems. The next steps are to implement the solution and measure its effectiveness, adjusting as necessary.</div> <div><br></div><div>While RCA begins by reacting to an event and trying to discover the root cause, with practice and several periods of analysis it can become a proactive tool, actually predicting when a problem is likely to take place. That can help change the culture of the facility from one of putting out fires to one of resolving problems while they’re still small. And that reduces risk.</div> <div><br></div><div>A useful way to break change, which can seem like an insurmountable task, into manageable chunks is called Plan-Do-Study-Act (PDSA). The main idea behind PDSA is to test the proposed change in a small area and analyze the results before implementing the change across the organization. </div><div><br></div><div>The “classic quality paradigm (structure, process, outcomes) can have another key component, which is a feedback loop,” said the quality report’s authors. Structure refers to staffing, processes to deficiencies and selected aggregated minimum data set measures, and outcomes to measures like ADL decline or pain, according to Mor. “In order to improve quality, providers should periodically engage in critical self-evaluation to assess the extent to which the quality improvement structures, processes, and outcomes they have committed to are actually being implemented.”</div> <h2>Identifying Early Indicators</h2> <div>BHS, which had two of the three AHCA/NCAL Step III Quality Award winners this year, is focusing on developing leading indicators, rather than always relying on lagging indicators. A lagging indicator might be a low satisfaction score on a survey. Leading indicators could predict the areas of dissatisfaction before they take place, so that they can be prevented.</div> <div><br></div><div>With lagging indicators, “the data is slow to get back,” says Redalen. “It could take up to six months to get the results, and by that time you could have a big problem.” With leading indicators, results come back very quickly. “Leading indicators are short-term indicators where you can measure data” and see it promptly, she says.</div> <div><br></div><div>A priority area for which BHS is implementing leading indicators is in the area of pain, says Redalen.</div> <div><br></div><div>Two years ago, BHS identified certain indicators—outcome-based measures—for the whole organization to monitor, says Jeri Reinhardt, director of quality for BHS. The organization uses the results of the monitoring to inform its strategic planning.</div> <div><br></div><div>The philosophy centers around five pillars of quality. These are:</div> <div>■ Care—to develop and deploy evidence-based care and systems to produce superior outcomes and ensure patient/resident safety;</div> <div>■ Service—to consistently exceed customer expectations;</div> <div>■ People—to be the work community of choice and a leader in values-based recruitment, retention, leadership development, and employee satisfaction;</div> <div>■ Finance—to optimize financial results while developing and deploying sustainable models; and</div> <div>■ Growth—to grow the ministry to both existing and new markets.</div> <div><br></div><div>For each pillar, lagging indicators have been traced for more than three years, says Reinhardt. For Care, they’re acquired pressure ulcers, prevalence of falls, percent of pain, and percent of pain for short-stay patients. For Service, the quality indicators are resident satisfaction and family satisfaction. For People, they’re the mission values survey, nursing employee retention for the skilled nursing portion of the facility, and employee retention for the assisted living portion. For Finance, the quality indicators are cash flow, fiscal year-to-date, and community benefit. And, finally, for Growth, they’re market growth, philanthropy, and grants.</div> <div><br></div><div>But saying “Let’s fix our overall satisfaction rate” is a daunting task. Instead, BHS looked at the lagging indicators and then identified leading indicators, such as “Do we acknowledge concerns within 24 hours of receipt?” If they’re not acknowledging concerns that quickly, staff can fix the process. That will help prevent any future issues from becoming full-blown problems, and, in turn, improve the satisfaction survey results.”</div> <h3>Continuous Quest For Quality</h3> <div>Reinhardt doesn’t think this is really anything new in long term care. “All long term care organizations have lots of things they measure,” she notes. “But do you actually look at what you measure, and do you find the meaning in it?” While having the measures isn’t rare, organizing them around a pillar with leading and lagging indicators is more so, she says. “What we’re trying to do is organize them around our pillars and identify the leading indicators that are most important to our future success.”</div> <div><br></div><div>Continuing to reach for ever-higher realms of quality is the vision of Anna Bojarczuk-Foy, administrator of ElderWood Health Care at Wedgewood in Amherst, N.Y., winner of an AHCA/NCAL Step III Quality Award. Receiving the award doesn’t mean Foy is going to rest on her laurels. In fact, as the Quality Awards examiners were conducting a site visit, she was already in the midst of further quality efforts.</div> <div><br></div><div>“Step III was an exceptional award for me and my staff—it’s our award—but if we stop now, we really don’t deserve it. You have to always continually challenge yourself to be better every day. If we settle in and say, ‘We got this [award], we’re great,’ we’re not going to be so great. When you take care of people it’s always changing, and technology changes, so we have to challenge ourselves to do more, to do things differently. I’ve been in [health care] for over 30 years, and I will never stop challenging the staff to see what we can do better or differently for next year. I’m thrilled that we got the Step III award, and it’s not by accident, because we worked hard for it. But we can’t stop now. We’re already on to other things.” </div> <div> </div> <div><em>Kathleen Lourde is a freelance writer based in Dacoma, Okla.</em></div> <div> </div>In long term care, the profession and government alike are pressing for more and faster quality improvement with an array of initiatives and tools. At the same time, the recession and cuts to Medicaid in many states, among other factors, have made just remaining operational difficult, much less finding the physical, personnel, and financial resources to expend on quality improvement efforts.2009-12-01T05:00:00ZColumn12